Three Part Question

In [patients with acute chest pain] what [is the sensitivity of abnormal peripheral pulses] for [diagnosing acute dissection of the thoracic aorta]

Clinical Scenario

A 63 year old man presents to the emergency department with a one hour history of central chest pain of sudden onset. ECG reveals ST elevation in his inferior leads. He has no obvious contra-indications to thrombolysis in his history but you wish to ensure he has no evidence of a dissecting thoracic aneurysm before giving streptokinase. To keep your door-to-needle time below 20 minutes you wonder whether excluding a pulse deficit clinically is sensitive enough to avoid waiting for X-ray.

Search Strategy

Medline 1966-05/04 using the OVID interface.
([disect$.af. OR dissect$.af] AND [aorta.af OR aortic.af] AND [thoracic.af OR chest.af OR thorax.af OR ascend$.af OR arch.af OR descend$.af] AND [pulse.af OR puls$.af]) LIMIT to human AND English language

Search Outcome

Altogether 89 papers found. One was a systematic review of the literature up to 2000. All relevant papers except 2 that post-dated it were included in this review. These three papers are summarised in the table.

Relevant Paper(s)

Author, date and country

Patient group

Study type (level of evidence)

Outcomes

Key results

Study Weaknesses

Klompas M,2000,USA

16 papers pooling sensitivity of pulse deficit in 1586 patients

Meta-analysis

Sensitivity

31% (95% CI 24-39%)

Majority of studies lacked control group.
Majority retrospective analysis of signs in patients with known dissection

Bossone E et al,2002Italy

513 patients with type A aortic dissection confirmed on imaging, surgery or post-mortem

Comment(s)

Few studies use a control group and use a top-down approach of assessing only patients with a dissection. This makes calculation of likelihood ratios difficult. There is yet to be a blinded bottom up trial of pulse deficit in thoracic aorta dissection. Interestingly it appears that pulse deficit may have use in the risk assessment of dissection.

Clinical Bottom Line

Pulse deficit has a sensitivity of around 30% in dissecting thoracic aortic aneurysm. This is far too low to be considered suitable as a SnOut and other investigations are required.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

Klompas M. Does this patient have an acute thoracic aortic dissection? JAMA 2002;287(17):2262-72.